Childhood Malnutrition: an Unintended Effect of SCHIP Expansion?

When Congress passed a major expansion of the State Children’s Health Insurance Program last year intended to enroll four million more children, it did so in a fiscally responsible way: it funded the expansion, over many Republican objections, with an increase in the federal tobacco tax. But a new study suggests the possibility that the very children the government is trying to cover with its SCHIP expansion might be facing problems because of that tax increase.

Professors Stephen Block and Patrick Webb of Tufts University published a study last fall looking at the links between poverty, smoking and childhood malnutrition on the Indonesia island of Java. What they found sounds pretty reasonable, if disheartening: In poor families, funds spent on tobacco often come out of household food budgets.

They found that households of nonsmokers spend on average 75 percent of their budget on food, whereas households in which at least one person smokes allocate 68 percent of their budget to food and 10 percent to cigarettes.“This suggests that 70 percent of the expenditures on tobacco products are financed by a reduction in food expenditures,” the researchers write.

Households with smokers allocate a larger portion of their food budget to rice, a low-nutrient food, whereas those of nonsmokers spent more on high-quality foods, like meats and vegetables.

They also found that preschool children in smoking households tended to be shorter than those in nonsmoking households, a common indicator of malnutrition.

Block and Webb’s findings echoed those of researchers at Berkeley and the World Health Organization, who also found that children of impoverished smokers often paid the price for their parents’ habits.

In the United States, people smoke less as they move up the income scale, meaning that children in households who qualify for SCHIP are disproportionately likely to have parents who smoke. The average state and federal excise tax burden of a pack of cigarettes is $2.35, though the total tax on a pack of cigarettes varies from $5.26 in New York City to $1.08 in South Carolina. While increased cigarette taxes often induce some people to quit and others not to start smoking, the demand for cigarettes remains relatively inelastic because of tobacco’s addictive properties — which is why cigarette taxes are often a boon to state and federal treasuries.

If the researchers at Tufts, Berkeley and the WHO are all right, increasing tobacco taxes could mean that, in some SCHIP-qualifying households where the parents remain smokers, children may suffer as their parents struggle to pay for tobacco and food.

Block and Webb note that one state has a program that has been much more effective at encouraging less-wealthy smokers to quit: Massachusetts.

When Massachusetts began offering next-to-free smoking cessation products in 2006, it hoped to reduce the number of low-income smokers within state lines. New data suggest that it has done so, and fast — by 2008, the proportion of poor smokers in the state dropped from 38 percent to 28 percent, a 30,000-person decrease (but still significantly higher than the rate in the general population, estimated at 21 percent).The program covers almost the entire cost of counseling and prescription drugs for Medicaid participants, capping copayments at $3. Enrollees aged 18 to 64 are eligible for 180 days of drugs and 16 counseling sessions per year. The total cost to the state was $11 million for the first two years.

That’s a total cost of $366.68 per smoker, a cost far outstripped by the cost of health care for smokers. (The Senate health care bill offers a very limited version of Massachusetts’ cessation coverage: Only pregnant women would qualify.)

These statistics indicate that both smokers who are Medicaid-eligible and their children would benefit more from programs that help them quit than from ones intended to make smoking less affordable.